Metabolic Screening Uncommon in Kids on Antipsychotics

Action Points

Explain to patients that screening for glucose and lipid abnormalities is uncommon in children treated with second-generation atypical antipsychotic drugs.

Note that the findings are based on a retrospective review of data from three states, not a prospective study.

Most children on antipsychotic medication do not get recommended metabolic tests even though they have an increased risk of glucose and lipid abnormalities, an analysis of a Medicaid claims database showed.

About 30% of these youngsters had glucose assessments and 13% had lipid evaluations, although they were twice as likely to have glucose or lipid abnormalities as a control group of children taking asthma medication, according to an article in the April issue of Archives of Pediatric and Adolescent Medicine.

"Results from this study suggest that serum glucose and lipid monitoring . . . are greatly underused in pediatric populations receiving antipsychotic drug treatment," Elaine Morrato, DrPH, of the Colorado School of Public Health in Denver, and colleagues concluded.

"Despite the result that use of glucose and lipid screening was higher in the antipsychotic-treated group than in an age-matched reference pediatric population, screening rates are markedly low, are lower than rates reported in antipsychotic-treated adults, and are well below the recommended goal that 'all patients' taking antipsychotics be monitored."

Children with mental disorders constitute a growing proportion of patients treated with second-generation atypical antipsychotics. Over the past decade, use of antipsychotic medications in the treatment of children has increased five-fold, currently accounting for a fourth of new prescriptions for these drugs (Arch Gen Psych 2006; 63: 679-85).

Rates of antipsychotic use in children have increased in a number of other countries, but remain lower than reported rates in the U.S., the authors wrote.

Since 2003 the U.S. Food and Drug Administration has required label warnings about metabolic risks associated with second-generation antipsychotic medications, including recommendations for patient monitoring (Psychiatr News 2003; 38: 1).

In 2004 several organizations (including the American Diabetes Association and American Psychiatric Association) issued a joint consensus statement recommending metabolic screening and monitoring of all patients taking second-generation antipsychotics, regardless of age (Diabetes Care 2004; 27: 596-01).

Most of the data on metabolic disturbances associated with second-generation antipsychotics have come from studies involving adults, the authors noted.

Relatively little information exists regarding short- and long-term metabolic effects of the drugs in children, despite evidence that the association between antipsychotic medication use and diabetes appears stronger in children than in adults (Ann Pharmacother 2008; 42: 1316-22).

In an effort to estimate the rate of metabolic screening in children starting treatment with second-generation antipsychotics, Morrato and colleagues analyzed Medicaid claims data from California, Missouri, and Oregon.

They identified 5,370 children ages 6 to 17 with no history of diabetes who started on second-generation antipsychotics from July 1, 2004 to June 30, 2006. For comparison, the authors identified 15,000 age-matched children without diabetes who were taking albuterol but no second-generation antipsychotics.

The primary objective was to determine rates of serum glucose and lipid testing, six-month incidence of diabetes, and rates of dyslipidemia. They also wanted to examine the influence of the ADA/APA recommendations on actual metabolic screening of patients taking second-generation antipsychotics.

The analysis showed that 1,699 (31.6%) of the patients on the antipsychotics had glucose screening compared with 1,891 (12.6%) patients in the control group. Lipids were assessed in 13.4% (720) of the antipsychotic group versus 3.1% (758) of the children taking albuterol.

"Screening rates were approximately one-quarter to one-half lower than rates reported for adults," the authors wrote.

The antipsychotic group had a higher case incidence of glucose and lipid disorders (8.9 per 1,000 children and 9.7 per 1,000, respectively) than did the control group (4.9 per 1,000 and 4.6 per 1,000, respectively).

The authors also examined rates of metabolic monitoring among persistent users of second-generation antipsychotics, defined as no gap in therapy greater than 30 days during the first 180 days of treatment. The analysis was based on the assumption that persistent users might have a greater risk of developing metabolic disturbances.

Among persistent users of antipsychotics, glucose abnormalities occurred within the first six months of treatment in 0.9% versus 0.5% of the control group (P=0.001). Lipid abnormalities were documented in 1% of the antipsychotic group and 0.5% of the control group (P<0.001). The rate of glucose and lipid disturbances did not differ by the type of antipsychotic prescribed.

Metabolic screening was more common in persistent users of second-generation antipsychotics, but still included only a minority of the patients (glucose testing in 45% and lipid testing in 22%).

Limitations of the study included reliance on laboratory testing and not on other clinical screening that might have taken place. There was also no information on what was done with screening results -- just whether or not testing was performed. There was also a possible lack of generalizability to a non-Medicaid population.

The finding that screen rates fell short of consensus recommendations "is disturbing, given the general environment of public health concern surrounding increasing rates of obesity and type 2 diabetes in adolescents and given specific concerns about metabolic risk for children with psychiatric conditions," the authors wrote.

"Recent approvals of pediatric indications for two additional second-generation antipsychotic drugs, with approval of a third drug still pending, suggest that the number of children receiving antipsychotic medication, and therefore requiring metabolic monitoring, will increase."

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